Welcome to the Radiology Section @ Chiro.Org! This section contains charts and guides to help you perform radiolographic examinations, and provides links to other radiology sites, and contains interesting articles on diagnostic imaging.

Chiropractic Radiology

This section was compiled by Frank M. Painter, D.C. Send all comments or additions to:Frankp@chiro.org

Our thanks to G. Patrick Thomas, Jr., DC, DACBR for originally developing this page! We wish him well in his retirement! He donated several useful charts, articles, and a radiology report generator, and they will remain here, archived permanently.

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Radiology Tools

Radiologic Manifestations of Spinal SubluxationsChapter 6 from:“Basic Chiropractic Procedural Manual”
By Richard C. Schafer, D.C., FICC and the ACAPress
This chapter describes the radiologic signs that may be expected when spinal subluxations are demonstrable by radiography. Through the years, there have been several concepts within the chiropractic profession about what actually constitutes a subluxation. Each has had its rationale (anatomical, neurologic, or kinematic), and each has had certain validity contributing to our understanding of this complex phenomenon.

The Radiology Book Shelf
Please browse our Radiology Book Shelf. Any books you purchase will help to support our non-commercial website.

Criteria to Screen for Traumatic Cervical Spine Instability:
A Consensus of Chiropractic Radiologists
J Manipulative Physiol Ther. 2018 (Feb); 41 (2): 156–163 ~ FULL TEXT
Twenty-nine chiropractic radiologists participated in round 1. After 3 rounds of survey, 85% of participants approved the final consensus-based list of criteria for traumatic cervical spine instability screening, including 6 clinical signs and symptoms and 5 radiographic criteria. Participants agreed that the presence of 1 or more of these clinical signs and symptoms and/or 1 or more of the 5 radiographic criteria on routine static radiographic studies suggests cervical instability.

A Videofluoroscopy-based Tracking Algorithm for Quantifying
the Time Course of Human Intervertebral Displacements
Comput Methods Biomech Biomed Engin. 2017 (Mar 15): 1–9
When applied to two patient cases, aberrant intervertebral motions in the cervical spine were typically found to correlate with patient-specific anatomical features such as disc height loss and osteophytes. The case studies suggest that intervertebral kinematic time-course data could have value in clinical assessments, lead to broader understanding of how specific anatomical features influence joint motions, and in due course inform clinical treatments.

Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin:
A Narrative Literature Review of History, Physical Examination,
and Diagnostic Imaging
Journal of Chiropractic Medicine 2016 (Dec); 15 (4): 281–293 ~ FULL TEXT
Musculoskeletal sources of adult hip pain can be divided into posterior, lateral, and anterior categories. For posterior hip pain, select considerations include lumbar spine and femoroacetabular joint referral, sacroiliac joint pathology, piriformis syndrome, and proximal hamstring tendinopathy. Gluteal tendinopathy and iliotibial band thickening are the most common causes of lateral hip pain. Anterior hip pain is further divided into causes that are intra-articular (ie, labral tear, osteoarthritis, osteonecrosis) and extra-articular (ie, snapping hip and inguinal disruption [athletic pubalgia]). Entrapment neuropathies and myofascial pain should also be considered in each compartment. A limited number of historical features and physical examination tests for evaluation of adult hip pain are supported by the literature and are discussed in this article.

Patients in Subgroup 1 had no or few MRI findings and therefore were labelled ‘No or few findings’.

Patients in Subgroup 2 had low sum scores on the variables related to spinal degeneration, with no or very few findings at the SIJs, and therefore were labelled ‘Mild spinal degeneration’.

Patients in Subgroup 3 had higher sum scores on the variables related to spinal degeneration than Subgroup 2, with no or very few findings at the SIJs, and therefore were labelled ‘Moderate/severe spinal degeneration’.

Patients in Subgroup 4 had similar sum scores on the variables related to spinal degeneration as Subgroup 3, but also MRI findings at the SIJ, and therefore were labelled ‘Moderate/severe spinal degeneration and mild SIJ findings’.

Patients in Subgroup 5 had lower sum scores of the variables related to spinal degeneration than Subgroup 4, but higher sum scores of findings at the SIJs, and therefore were labelled ‘Mild spinal degeneration and moderate/severe SIJ findings’ (see Figure 2 for details).

Bladder Metastasis Presenting as Neck, Arm and Thorax Pain:
A Case Report
Chiropractic & Manual Therapies 2016 (May 4); 24: 14 ~ FULL TEXT
This patient presented in November 2014 with progressive neck, thorax and upper extremity pain. Computed tomography revealed a destructive soft tissue mass in the cervical spine and additional lytic lesion of the 1st rib. Prompt referral was made for surgical consultation and medical management. Distant metastasis is rare, but can present as a musculoskeletal complaint. History of carcinoma should alert the treating chiropractic physician to potential for serious disease processes.

Pathological Burst Fracture in the Cervical Spine
With Negative Red Flags: A Case Report
J Can Chiropr Assoc. 2016 (Mar); 60 (1): 81–87 ~ FULL TEXT
A 61–year-old man presented to a chiropractic clinic with neck pain that began earlier that morning. After a physical exam that was relatively unremarkable, imaging identified a burst fracture in the cervical spine. The patient's initial physical examination was largely unremarkable, with an absence of clinical red flags. The screening tools were non-diagnostic. Pain with traction and the sudden onset of symptoms prompted further investigation with plain film imaging of the cervical spine. This identified a pathological burst fracture in the C4 vertebrae.

Radiology Undergraduate and Resident Curricula:
A Narrative Review of the Literature
Journal of Chiropractic Humanities 2015 (Dec); (22) 1: 1–8 ~ FULL TEXT
Formal radiology education is not taught at all medical programs and little radiology training is incorporated into non-radiology residencies. This results in some medical graduates not being taught how to interpret basic radiology images and not learning contraindications and indications for ordering diagnostic imaging tests. There are no definitive studies examining how to incorporate radiology into the curriculum, how to teach radiology to either undergraduates or residents, or how to assess this clinical competency.

MRI Spine Protocols
The American Chiropractor ~ September 25, 2013 ~ FULL TEXT
First, as I have discussed previously, general radiologists have a 42.2% error rate as reported by Lurie, Doman, Spratt, Tosteson, and Weinstein (2009), which makes it virtually imperitive that we, as practitioners, must take control of a critical component in diagnosing our pateints. At the very least, we must understand the basics of MRI spine interpretation to verify the findings or lack thereof. We also must be congnizant of the fact that we often rely on the MRI when ordering and delivering high velocity thrusts into our pateints. At this level, accuracy matters in determining a correct prognosis and treatment plan to ensure the safety of our patients when adjusting the spine. It is imperative for chiropractic.

The Pediatric Elbow: A Review of Fractures
Dynamic Chiropractic ~ FULL TEXT
The elbow fracture is one of the most common fractures in children. Assessing the elbow for fracture can be difficult because of the changing anatomy of the growing skeleton and the subtlety of some of these fractures. It's important to be aware of the radiographic signs of fracture in the elbow, along with knowing the appearance and fusion of the ossification centers in the pediatric patient, to avoid confusing an ossification center with a fracture fragment. Of course, alignment and radiographic positioning are also extremely important in making a diagnostic assessment.

Multiple Myeloma Presenting as Sacroiliac Joint Pain:
A Case Report
J Can Chiropr Assoc. 2012 (Jun); 56 (2): 94-101 ~ FULL TEXT
Multiple Myeloma (MM) is the most common primary cancer of bone in adults. The clinical presentation of MM is varied and depends on the sites and extent of involvement. Most importantly for chiropractors, the leading clinical symptoms of MM are related to bone neoplasm and may mimic pain of musculoskeletal origin. The following is the case of a 56 year old male chiropractic patient presenting with a 6 month history of sacroiliac joint pain previously diagnosed and managed unsuccessfully as a hematoma by multiple providers. Physical examination, imaging, and laboratory investigations confirmed a diagnosis of MM. The case report describes relevant pathophysiology, clinical presentation, imaging, and management for MM, while illustrating key issues in patient management as they relate to chiropractic practice and the recognition of pathology in the context of musculoskeletal pain.

Scheuermann's Disease:
A Poorly Understood Abnormality of the Adolescent Spine
Dynamic Chiropractic ~ FULL TEXT
Scheuermann's disease (SD) – osteochondritis of vertebral epiphyseal plates or adolescent kyphosis – was first described in 1921 by Holger Werfel Scheuermann, a Danish surgeon, as an osteochondrosis with cause unknown involving the spine and frequently causing lower thoracic kyphosis. The term juvenile kyphosis has sometimes been used to designate this condition. Although many theories have been proposed, the cause of SD is still unknown. Currently under investigation are the roles of juvenile osteoporosis, hereditary factors, biomechanical factors, and a variety of other causes, but to date no specific etiology has been determined, except that there is a disruption in the normal development of the vertebral end plate.

SPECT/CT Imaging of the Lumbar Spine in Chronic Low Back Pain:
A Case Report
Chiropractic & Manual Therapies 2011 (Jan 11); 19: 2 ~ FULL TEXT
Mechanical low back pain is a common indication for Nuclear Medicine imaging. Whole-body bone scan is a very sensitive but poorly specific study for the detection of metabolic bone abnormalities. The accurate localisation of metabolically active bone disease is often difficult in 2D imaging but single photon emission computed tomography/computed tomography (SPECT/CT) allows accurate diagnosis and anatomic localisation of osteoblastic and osteolytic lesions in 3D imaging. We present a clinical case of a patient referred for evaluation of chronic lower back pain with no history of trauma, spinal surgery, or cancer. Planar whole-body scan showed heterogeneous tracer uptake in the lumbar spine with intense localization to the right lateral aspect of L3. Integrated SPECT/CT of the lumbar spine detected active bone metabolism in the right L3/L4 facet joint in the presence of minimal signs of degenerative osteoarthrosis on CT images, while a segment demonstrating more gross degenerative changes was quiescent with only mild tracer uptake. The usefulness of integrated SPECT/CT for anatomical and functional assessment of back pain opens promising opportunities both for multi-disciplinary clinical assessment and treatment for manual therapists and for research into the effectiveness of manual therapies.

Accurate Prognosis in Personal-Injury Cases Using George's Line
Dynamic Chiropractic ~ March 26, 2010 ~ FULL TEXT
The AMA's Guides to the Evaluation of Permanent Impairments uses George's Line to rate neck impairments. A moderate (3.5 mm) break in George's Line on the flexion and extension lateral X-ray films is a permanent impairment, equivalent to a post-surgical fusion of two cervical vertebra. Most chiropractors see small anterolisthesis and/or retrolisthesis on the films and ignore it or fail to appreciate its significance. Since 35 percent to 45 percent of trauma patients have this injury, it is very likely you have failed to diagnose it many, many times. By failing to diagnose this injury, you have failed to accurately, thoroughly and honestly describe your patient's injuries to the claim adjusters and attorneys, who will use the facts in your patient chart as the basis for the personal-injury settlement. These people need you, the doctor, to give them all the facts so a fair settlement can be reached. The jury also needs to understand whether your patient had this injury in order to decide how much to award your patient in a trial verdict.

The Effect of Backpacks on the Lumbar Spine in Children:A Standing Magnetic Resonance Imaging Study
Spine (Phila Pa 1976) 2010 (Jan 1); 35 (1): 83–88 ~ FULL TEXTThis is the first study to use advanced imaging to demonstrate how backpack loads are responsible for a significant amount of back pain in children, which in part, may be due to changes in lumbar disc height or curvature. This is the first upright MRI study to document reduced disc height and greater lumbar asymmetry for common backpack loads in children.

Injuries in the Pediatric Patient:
Review of Key Acquired and Developmental Issues
J Clinical Chiropractic Pediatrics 2009 (Dec); 10 (2): 665–670 ~ FULL TEXT
A plethora of conditions specifically target children and adolescents which are not prevalent in the adult population. Understanding the age-related differences in this population can help clinicians improve diagnosis and therefore management of these conditions. Though it is beyond the scope of this paper to extensively address diseases targeting the pediatric population, common key injuries will be discussed with emphasis on the role imaging plays in establishing accurate diagnosis.

Sacral Stress Fractures: Tracking Down Nonspecific Pain in Distance Runners
The Physician and SportsMedicine 2003 (Feb); 31 (2) ~ FULL TEXT
Sacral stress fractures are an underrecognized cause of low-back and gluteal pain in distance runners. The combination of low bone density and increased activity blurs the boundary between fatigue and insufficiency fractures in many runners. MRI is the preferred radiologic technique because of its ability to localize the site of injury and rule out tumors, disk disease, or sacroiliitis. By identifying the condition early, clinicians contribute to a favorable outcome and help most athletes return to full activity in 12 to 14 weeks.

MRI of the Temporomandibular Joint
A wide variety of conditions affect the temporomandibular joint (TMJ) including congenital anomalies, ankylosis, arthritis, and internal disk derangement (1). TMJ disease is common, affecting between 4 and 28 percent of the population. Young females in particular commonly present with TMJ complaints (2).

Diagnostic Imaging of Meniscal Injuries
Radiographic examination of the knee is often unrewarding, despite physical and orthopedic findings that clearly indicate an abnormality. Much of the supporting anatomy of the knee is invisible with conventional radiography, but more sophisticated techniques can be used to demonstrate these important structures. Magnetic resonance imaging is able to delineate the cruciate ligaments and menisci, providing the clinician a more complete and accurate view of the patient’s condition.

The Azygos Lobe
This normal variant occurs in less than 5% of the population. Despite it's characteristic shadow, it often alarms physicians not familiar with it's apearance. The azygos lobe forms when the azygos vein fails to migrate over the apex of the lung during fetal life.

Back Pain in Children
Virtual Pediatric Hospital
A commonly held belief in pediatrics is that back pain in children is rare, and its presence almost always heralds a serious underlying disorder. In reality, this belief only holds true in the prepubertal child, in whom back pain is rare, and if present often has a serious underlying cause. In adolescent children, chronic back pain may be found in up to 13% of them, but the underlying cause is often a sports induced injury. The job of the family practitioner or pediatrician seeing a child with back pain is to distinguish the serious from the non serious causes of back pain.

Paediapaedia: An Imaging Encyclopedia of Pediatric Disease
Paediapaedia is aimed at the radiology resident learning pediatric radiology for the first time, the pediatric radiology fellow mastering pediatric radiology for the first time, and for the general radiologist who does a small amount of pediatric imaging on a daily basis. Paediapaedia is meant to be a handbook of pediatric radiology. It is designed to let you get at the information you need easily and rapidly. It is meant to put the information you need most often at your fingertips.

Deborah Pate, DC, DACBR Articles

Joint Pain in Children: A Series of 7 Articles
Dynamic Chiropractic ~ FULL TEXT
Joint pain is a common complaint in children but seldom a symptom of serious joint disease. How can you determine if a child with knee pain has just a strain/sprain or a more serious joint disease, such as Lyme disease, rheumatic fever, or juvenile rheumatoid arthritis? This series of articles reviews the more common joint disorders affecting children.

The Pediatric Elbow: A Review of Fractures
Dynamic Chiropractic ~ FULL TEXT
The elbow fracture is one of the most common fractures in children. Assessing the elbow for fracture can be difficult because of the changing anatomy of the growing skeleton and the subtlety of some of these fractures. It's important to be aware of the radiographic signs of fracture in the elbow, along with knowing the appearance and fusion of the ossification centers in the pediatric patient, to avoid confusing an ossification center with a fracture fragment. Of course, alignment and radiographic positioning are also extremely important in making a diagnostic assessment.

Scheuermann's Disease:
A Poorly Understood Abnormality of the Adolescent Spine
Dynamic Chiropractic ~ FULL TEXT
Scheuermann's disease (SD) – osteochondritis of vertebral epiphyseal plates or adolescent kyphosis – was first described in 1921 by Holger Werfel Scheuermann, a Danish surgeon, as an osteochondrosis with cause unknown involving the spine and frequently causing lower thoracic kyphosis. The term juvenile kyphosis has sometimes been used to designate this condition. Although many theories have been proposed, the cause of SD is still unknown. Currently under investigation are the roles of juvenile osteoporosis, hereditary factors, biomechanical factors, and a variety of other causes, but to date no specific etiology has been determined, except that there is a disruption in the normal development of the vertebral end plate.

Treatment of Disk Herniation:
New Study Compares Surgical vs. Nonoperative Treatment
Dynamic Chiropractic ~ FULL TEXT
In this study, there were two broad treatment categories compared; surgical intervention and nonoperative care. Patients in the surgical group received a standard open diskectomy with examination of the involved nerve root. The nonoperative treatment group received "usual care," with the study protocol recommending that minimum nonsurgical treatment include at least active physical therapy, education/counseling with home exercise instruction, and nonsteroidal anti-inflammatory drugs, if tolerated. Other nonoperative treatments included CMT, acupuncture, braces, magnets, TENS and orthotics. The physicians participating in the study were encouraged to individualize treatment to the patient. I think it's interesting that out of 323 patients in the nonoperative treatment group, only 36 received chiropractic care, as opposed to 142 who received physical therapy. (For more information, take a look at table 2 in the original article.)

Are You Evaluating Your Patients for Osteoporosis?
Dynamic Chiropractic ~ FULL TEXT
The National Osteoporosis Foundation (NOF) recommends drug therapy for osteoporosis in patients with T-scores of –1.5 or lower and other risk factors. The NOF also recommends drug therapy for patients with T-scores of -2.0 or lower and no other risk factors. No, I am not referring to baseball scores; this regards osteoporosis, which affects approximately 28 million people in the United States.2 I know I have addressed this topic before, but I am now much more aware of this disorder. In fact, this evening, I read about 20 studies on osteoporosis, and noted three compression fractures in three different patients – all men, aged 23, 56, and 83 years. In general, I don't expect to see many compression fractures in that small a series of studies, so I guess I was impressed.

The QUIZ Section

Diagnostic Imaging Case Reports:

Thanks to ChiroAccess for access to these quizzes, provided by Jack Henry, DC, DACBR

Do You Observe Cervical Trauma On These Films?
A 17-year-old male reports status post trauma secondary to “mild” flexion/extension type injury. ROM was somewhat limited. Neurological and orthopedic evaluations were unremarkable. REVIEW THE FILMS AND YOU MAKE THE CALL!

A 62-year-old female reports low back pain
A 62-year-old female reports low back pain of four weeks. Pain is most intense in the early morning. No history of recent trauma was reported. The patient’s past medical history and physical exam findings were not provided.

The WHO Manual of Diagnostic Imaging:
Radiographic Anatomy and Interpretation
World Health Organization (2002) (209 pages) ~ FULL TEXT
Modern diagnostic imaging offers a vast spectrum of modalities and techniques, which enables us to study the function and morphology of the human body in details that approaches science fiction. However, it should be noticed that even in the most advanced Imaging Department in the economically privileged parts of the world, 70–80% of all clinically relevant questions may be solved by using the two main cornerstones of diagnostic imaging, which are Radiography (X-ray) and Ultrasonography.